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08255040022 <br /> ere <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CIWMB <br /> tCal("•ia Survey Form - Page 1 -1 1 - 10 10 <br /> 8 l 3 <br /> CIWMB 181(New nage <br /> CaSur Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- / O / Inspection Type (Fill one) <br /> Site Suffix: 7 1 -3 111 Y 12] IR Routine Q Re-inspection Q Referral Q Observation <br /> Localn � If Referral,choose referral type(Fill one) <br /> Identifier: �s.f2 �•L!/� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> (Physical Address IT9] <br /> _j <br /> Street rJ a l 2 l <br /> I _SXeyeAN Inspection Date Q <br /> City (� State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> m 'm0PM 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> I <br /> Tire Count(Whole/PTE) (Fill one only) ( apply) <br /> ( apply) <br /> ( pp Fill all that a I Fill all that a I Fill all that apply)� 1 � I f � <br /> 3 <br /> 0 Active ®Passenger 0 Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ��,�� Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — 7-1-1. <br /> I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 1 <br /> Q New Tire Dealer •.Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body B Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other 1 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice iW Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> El <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXTJ <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/C-IWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In C-ompliance No Yiotatlons <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included:Q /f l 0.91) <br /> Comments Included:Q AsAe 's &nr B Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 1(t X A M P IL l Z 3 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy:LEA ® . <br />